Saturday, January 11, 2003

If I could be the “condom queen” and get every young person who engaged in sex to use a condom in the United States, I would wear a crown on my head with a condom on it! I would!-Joycelyn Elders former Surgeon General of the United States. As quoted in the New York Times Magazine, January 30, 1994.

The difficulties of compliance with condom use, even in a cohort of research subjects, should make us pause and think about crusades for the supremacy of the condom in preventing the transmission of HIV.- editorial in the New England Journal of Medicine commenting on the paper that has been used to buttress condoms as the linchpin of safe sex practices, August 1994.

Over the last few years conservative groups in President Bush's support base have declared war on condoms, in a campaign that is downright weird — but that, if successful, could lead to millions of deaths from AIDS around the world.

I first noticed this campaign last year, when I began to get e-mails from evangelical Christians insisting that condoms have pores about 10 microns in diameter, while the AIDS virus measures only about 0.1 micron. This is junk science (electron microscopes haven't found these pores), but the disinformation campaign turns out to be a far-reaching effort to discredit condoms, squelch any mention of them in schools and discourage their use abroad.

So far so good. There are groups out there who make this claim. They are misinformed. A latex condom that has been kept sealed in its wrapper does not have pores this size discernable by electron microscopy. A latex condom left exposed to air for 72 hours does. (Sorry, I would provide a link but my source comes from the pre-internet days of JAMA.)

Kristof then goes on to quote some over-the-top statements by groups that favor abstinence:

"The only absolutely guaranteed, permanent contraception is castration," one Catholic site suggests helpfully. Hmmmm. You first.

Then there are the radio spots in Texas: "Condoms will not protect people from many sexually transmitted diseases."

A report by Human Rights Watch quotes a Texas school official as saying: "We don't discuss condom use, except to say that condoms don't work."

Which leads into his assault on the Bush Administration:

So far President Bush has not fully signed on to the campaign against condoms, but there are alarming signs that he is clambering on board. Last month at an international conference in Bangkok, U.S. officials demanded the deletion of a recommendation for "consistent condom use" to fight AIDS and sexual diseases. So what does this administration stand for? Inconsistent condom use?

Maybe what they stand for is presenting the role of condoms in preventing HIV and other sexually transmitted diseases realistically. (See this rundown of some of the drawbacks of complete reliance on condoms. And this.) Maybe what they stand for is using the same sort of language that responsible medical organizations use when discussing the role of condoms. Here is the American Academy of Family Physicians statement on condoms and sexually transmitted diseases:

The AAFP endorses and encourages the following HIV, STDs and blood borne infections prevention strategies:

1. The most effective strategies to prevent sexual transmission are abstinence and the maintenance of life-long mutually monogamous relationship with one uninfected partner. For individuals choosing to be sexually active in other situations, the following are generally effective for infections transmitted through bodily fluids:

·Engaging in sexual activities that do not involve or lead to vaginal, anal, or oral intercourse;
·Having intercourse with one uninfected partner;
·Using latex and other effective condoms in a correct manner from the start to finish of every episode of intercourse

For the individual, however, condom use, even if consistent and correct, does not ensure prevention of unintended pregnancy or acquisition of an STD or HIV. It is for this reason that abstinence remains the major focus of primary prevention in efforts to decrease adolescent pregnancy, STDs, and HIV infection, whereas condom use is the main focus of secondary prevention for those who are already sexually active and plan to remain so.

Maybe, they stand for telling the truth instead of promoting false assurances of the effectiveness of condoms. But, of course, the whole column’s purpose so far was to give the tempest over the changes in wording on condoms at the CDC website more importance than it deserves:

Then there was the Condom Caper on the Web site of the Centers for Disease Control. A fact sheet on condoms was removed in July 2001 and, eventually, replaced by one that emphasized that they may not work.

"The Bush administration position basically condemns people to death by H.I.V./AIDS," said Adrienne Germain, president of the International Women's Health Coalition. "And we're talking about tens of millions of people."

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and you know is uninfected.

For persons whose sexual behaviors place them at risk for STDs, correct and consistent use of the male latex condom can reduce the risk of STD transmission. However, no protective method is 100 percent effective, and condom use cannot guarantee absolute protection against any STD. Furthermore, condoms lubricated with spermicides are no more effective than other lubricated condoms in protecting against the transmission of HIV and other STDs. In order to achieve the protective effect of condoms, they must be used correctly and consistently. Incorrect use can lead to condom slippage or breakage, thus diminishing their protective effect. Inconsistent use, e.g., failure to use condoms with every act of intercourse, can lead to STD transmission because transmission can occur with a single act of intercourse.

While condom use has been associated with a lower risk of cervical cancer, the use of condoms should not be a substitute for routine screening with Pap smears to detect and prevent cervical cancer.

That’s no different than the statements of the American Academy of Family Physicians and the American Academy of Pediatrics. It’s medically sound advice. Condoms aren’t 100% effective in protecting against either pregnancy or sexually transmitted diseases. People deserve to know that rather than being fed false reassurances that all they have to do to prevent infection is wear a condom. I haven’t been able to find a copy of the CDC’s old fact sheet. I’m sure that reading it would provide an informative contrast. Especially if it had been penned under the influence of people like Joycelyn Elders, condom enthusiast par excellence. Which makes me wonder why it hasn't been reproduced by all of these people crying so loudly about its demise. Could it be that the old fact sheet wouldn't hold up to scrutiny?

1. "perfect use" of condoms is 98% effective (2/100 pregnancies per year), and
2. "practical use" of condoms is somewhere between 86% and 98% effective, probably closer to 86%-88% effective.

relative to what most teens are told and what they expect, I think that 13 pregnancies per 100 annual rate is astonishing . . . . . . hope you'd mention that, next time.

Consider it mentioned.

UPDATE II: Justin Katz has found the old condom fact sheet. (warning: pdf file), and as expected, it overstates the case for condom effectiveness. Justin also has a terrific take down of the Kristof column.

Killing Them Softly: In the Netherlands, where euthanasia is legal, the Supreme Court has ruled it illegal to kill a patient simply because they're sick of life. The case involved a general practioner and a former senator:

In 1998 Dr Sutorius helped former senator Edward Brongersma to die, even though he had no serious physical or mental illness. Mr Brongersma had often spoken with Sutorius of his wish to die. He suffered from physical decline and struggled with his "pointless and empty existence."

The appeal court had accepted the argument that Mr Brongersma's suffering was not medical and that GPs therefore had no experience to judge such an issue.

Dr Sutorius appealed to the Supreme Court in order to quash his conviction and clarify the position of doctors. The Supreme Court argued that last year's euthanasia law specifically did not cover such "tired of life situations." Its decision underlines the earlier judgment that "unbearable and hopeless suffering," a criterion laid down in the law on euthanasia, must be linked to a recognisable medical or psychiatric condition.

It’s so difficult to decide whose best interest the doctor is serving in these cases - the patient’s or his own. Patients who are anxious and obsessed about their health can be taxing. Just ask England’s Dr. Shipman, who was quite proficient at ridding himself of nuisance patients:

Shipman often killed patients who had a chronic condition which required a great deal of medical attention. For example, Mrs Alice Gorton, whom he killed in 1979, had terrible psoriasis. Shipman visited her very frequently to give her the supplies of the ointments and dressings she required. Mr Joseph Wilcockson, who was killed on 6th November 1989, had a painful ulcer on his leg, which was probably never going to heal. The district nurse attended regularly to dress it. Mrs Beatrice Toft had severe lung disease and used an oxygen cylinder. She had been into hospital on a number of occasions in the past and would plainly have needed a great deal of care had she lived out the terminal stage of her illness. None of these patients was close to death, however, and the suddenness of their deaths might have aroused suspicion. I suspect that Shipman selected patients such as these, who were or were about to be very demanding of his time and the resources of the practice. That he was concerned about resources is apparent from a remark he made about Mrs Edith Calverley, who had severe respiratory problems and was taking several different types of medication. After her death, Shipman remarked to the district nurse, 'That's one off my drugs bill'.

... Miss Joan Harding and Mrs Ivy Lomas, both of whom were killed in the surgery, suffered from anxiety and depression and consulted Shipman regularly. After Shipman had killed Mrs Lomas, he 'joked' to Police Sergeant (then Police Constable) Phillip Reade that Mrs Lomas had been such a nuisance that he had considered having a seat in his waiting area set aside for her, and having a plaque mounted which said 'Seat permanently reserved for Ivy Lomas'.

Read the whole description of Shipman’s patient selection. It’s the account of one man’s journey down the slippery slope of euthanasia.

And Not So Softly: Australia’s own Dr. Death is coming to America to show off his suicide machine to The Hemlock Society:

Dr. Philip Nitschke will present his device, which allows a person to breathe in pure carbon monoxide to hasten death, this weekend in San Diego, California, at the national conference of the Hemlock Society USA, a volunteer euthanasia group.

America’s Dr. Death is otherwise occupied, so Dr. Nitschke will do in a pinch. Nitschke gained international notoriety last year when he helped, some would say pressured an Australian woman with terminal cancer to commit suicide. Trouble was, she didn’t have cancer, nor was she terminally ill. And, while Dr. Nitschke is touting his suicide machine today, his ultimate goal is suicide pills for all. Lucky us.

Malpractice Bandwagon: Consumer activist groups are hoping to use the malpractice crisis to promote their own legislation for patient safety:

Consumer groups including Public Citizen and the Consumer Federation of America said lawmakers should pass legislation on medical errors, including disclosure rules and safety standards. They said high malpractice premiums also reflect weak insurance profits and investment decisions, not frivolous malpractice suits.

"Prevention is the cheapest remedy," Public Citizen president Joan Claybrook told a news conference. "That is what will make patients safer, that is what will prevent lawsuits, that is what will bring down premiums."

Safety standards may well be needed, but there's no reason to think that they'll reduce exorbitant jury awards, reduce the filings of frivolous lawsuits, or bring down insurance premiums. If it were truly bad medicine and bad doctors driving the large jury awards, then the areas with the greatest malpractice problems would be those with the poorest medical reputation. But it isn't that way. The largest malpractice problems exist in places with no tort reform on the books, and with prolifigate malpractice attorneys - Philadelphia, Cleveland, Las Vegas, and, until recently, Mississippi.

I am not arguing that safety standards aren’t important - they are. They are important for appropriate patient care. And they are in the best interest of the patient. But it’s misguided to think that better safety standards can take the place of tort reform to solve the malpractice insurance crisis.

Frontline Report: A reader emailed this report of his experiences with monitoring quality of care as a member of a peer review organization (PRO):

The other physician consultants I worked with were varied in their backgrounds and specialties, and all were decent docs. After allowing for differences in practice styles and opinions, we could generally come to some agreement on what constituted a serious mistake. We had the ability to pull additional charts on a given physician or hospital so we could see if the mistakes were isolated or were part of a pattern. The PRO staff were good people, mostly nurses, who were experienced in the work and could ferret out amazing information.

The PRO process was supposed to be Medicare's answer for improving medical care and punishing bad doctors. You don't hear much about these PROs today, do you? The reason is, the whole concept failed miserably, and here's why.

1) The time and effort spent to deal with one serious but isolated mistake was disproportionate to the mistake. The only penalties the PRO could recommend were a) fines, b) exclusion/suspension from Medicare, or c) corrective action plans. No one wanted to do a or b for an isolated mistake. Corrective action plans were generally cumbersome and inefficient, and more so when recommended in cases of repeated mistakes. As one of my colleagues said, "what are we supposed to do, make Dr. X repeat his residency? He didn't learn it the first time, why should we think he'll learn it now?" Because of the layered process of review in which a doctor could be forgiven at multiple levels, the number of exclusions recommended per year was generally about one -- this in a state with 20,000 plus doctors. And the OIG [Office of Inspector General at the Department of Health and Human Services -ed. note] accepted only a fraction of these.

2) The reluctance of physicians to discipline their own. As part of my chairing the aforementioned committee, I had to make presentations to the parent committee that would communicate with the OIG. The docs on that committee saw themselves as the Horatios at the bridge. No mistake was so great as to warrant forwarding to OIG. In one heated debate (about a physician with multiple, multiple serious errors in basic medical practice) in which my committee was recommending exclusion from Medicare, a doctor on the parent committee exclaimed, "but how will this doctor make a living?" My response was, "he can sell shoes." As you might imagine, that didn't go over well.

3) The randomness of the review process. Even with a cadre of reviewing nurses and physicians, the total number of inpatient records we could review was a fraction of the yearly hospitalizations in our state. We spent a lot of time developing algorithms that would focus the review effort, but in truth this didn't work very well. So you could never be comfortable that you were really identifying issues and mistakes that, when corrected, would lead to real improvements in medical care.

PROs still exist, but their efforts are now merely a sideline. If we as physicians ever wanted to be serious about improving medical care, we have to find ways to bring up care in a systems-based approach such as the total quality improvement processes practiced by companies such as Xerox and Motorola. We have to find ways to help doctors who are deficient in their practices catch up without creating new antagonisms. We need to have the spine to run dangerous doctors out of the profession.

Until we do, the med-mal lawyers are about the only realistic disciplinary process we have. Hospital credentialing committees are always vulnerable to charges of political and economic conflict, and
state boards are, shall we say, under-funded, under-staffed and under-competent.

Just one opinion from someone who was formerly at the front line of this.

I agree that we aren't particularly good at policing our own, and that malpractice lawyers serve a purpose. I don't want to see the tort system gutted. I do want to see it reformed so that it can’t be so easily abused by the bad apples in the legal profession. (A profession, by the way, that is even worse at policing its own than medicine is.)

Not Einstein's Brain: Some reflections on the coverage of the Raelians:

It's hard to pick the most cringe-making moment of this story, which proved decisively that journalists can't distinguish science from science fiction. Was it when Anna Maria Tremonti, a woman of impeccable authority, attempted to interview the chief Raelian on the CBC? Was it the fetching outfits of Brigitte Boisselier, the PhD who looks like a dominatrix in a whorehouse? Was it Connie Chung's session with Rael on CNN, when he insisted that she address him as "His Holiness"? And she did?

Not-So-Demon Rum: Chalk another one up for the health benefits of booze:

"It was a surprise that -- almost regardless of other factors associated with drinking -- frequency of use seemed to be what reduced the subsequent risk of a heart attack," said Dr. Kenneth Mukamal of Harvard University Medical School, who led the study.

Those who drank at least three days a week had about one-third fewer heart attacks than did non-drinkers. And it made almost no difference whether the drinking consisted of half a drink or four. Those who imbibed only once or twice a week had only a 16 percent lower risk of a heart attack.

The study did show a definite trend toward fewer heart attacks in those who drank the most. Three percent of the people who had more than five drinks a day had heart attacks, compared to six percent of the tee-totalers. And among those who drank the most there was a definite preference for beer and liquor over wine. So much for the old doctor’s advice to drink like the French not like the Irish.

Flu Season: Just in time for flu season comes a study showing that it's killing us at higher rates. The study has some problems, though:

But the paper did not reveal the details of the statistical analysis, nor did it provide influenza death rates for people of different ages. That, in particular, was a serious drawback, said Dr. David Freedman, a statistician at the University of California at Berkeley. "It is startling to see a paper without age-specific death rates," Freedman said, because without them it is impossible to assess the scientists' conclusions that the increased deaths were solely because of increased numbers of elderly people.

The study also uses a different statistical model than the ones used for the past decades to which it compares its results. Not exactly solid science. It makes sense, though, that as the number of the aged increases, so will the number of deaths from influenza and other illnesses:

"Now public health and medical communities must also face the looming confrontation between an unstoppable force and an immovable object, the aging of the baby boom generation and the predictability of annual influenza," he wrote. "Simple demographics practically ensure an impending public health disaster of great proportion.

We all have to die sometime, and the number of deaths is going to keep increasing as the baby boomers reach their older years. That doesn’t necessarily qualify as a “public health disaster” but it will probably be framed that way, even when they’re dying of old age.

State of Smallpox: In response to the email I posted yesterday about the pros and cons of smallpox vaccine, a Canadian reader had this to say:

Regarding the availability of smallpox outside of protected stocks in the United States and Russia, I think Richard Preston makes a good case to the contrary in his recent book "Demon in the Freezer." Iraq had its last smallpox outbreak in 1972; it launched its covert bioweapons program the following year, a fact which has been documented by UN weapons inspectors.

To assume that Iraq would have destroyed its own stocks of smallpox just as it began developing biological weapons is dubious, to say the least. To be sure, we don't have a smoking gun. But not even a court of law requires absolute proof of guilt to convict a suspect; circumstantial evidence is often quite sufficient even to convict for murder. And there is plenty of circumstantial evidence where Iraq is concerned.

The U.S. military assumes that North Korea, as well as Iraq, has samples of the smallpox virus, and it's possible the two countries have exchanged information on that and other biological weapons, Henchal said. He said "it's a bit of a fantasy" to assume that the only smallpox samples in the world are the two publicly declared samples in the United States and Russia.

"It's clear from intelligence that the genie is out of the bottle," Henchal said.

Trained translators provided by the hospital, involved in six of the encounters, made almost as many errors as the nurses, social workers, strangers or siblings who translated in the other cases. The errors by the trained translators were less likely to be important; still, half were rated as medically significant.

Over all, about half of the errors were omissions - neglecting to tell the doctor important facts or failing to ask about allergies. Other errors were categorized as substitutions, editorialization and addition. One interpreter told a woman not to answer some of the doctor's questions because they were "personal"; another told a mother to put antibiotics for her child's ear infection in the baby's ears.

I've often wondered what interpreters were really telling my patients. Sometimes a long sentence by me will come out as three words from the interpreter. And sometimes the patient will tell a big long story to the interpreter that becomes just one sentence in the interpretation.

Then, there's the matter of thinking we're all on the same page when we aren't:

Not all the mistakes were by the interpreters. The study found that physicians made a large number of what they called errors of false fluency - assuming that they or the patients understood something correctly when they did not. This kind of error was most common when a trained interpreter was involved in the encounter but was distracted or briefly called away.

This kind of error is also common between two people who supposedly speak the same language. I once had a patient who was treated by a surgeon and oncologist for an inoperable abdominal tumor. She had even been referred by the oncologist for an experimental trial of chemotherapy. When the disease had metastasized to her liver, she enrolled in hospice. When the hospice nurse went to visit her and mentioned her cancer, she freaked out. She always thought of her disease as a tumor, not a cancer. When I tried to remember my conversations with her, I realized I always said things like, "How's your chemotherapy going?" I never said "How's your cancer?"

Then, there's the matter of cultural differences. The first time someone told me they had piles, I had no idea what they meant. And when an elderly black man says he's having trouble with his nature, he doesn't mean his personality. What he wants is Viagra.

E-Medicolegal Implications: A reader who’s both a doctor and a lawyer (No, his name wasn’t Jekyl-Hyde) had this to say about e-medicine consults:

The practice of online consultations is probably malpractice. The Federation of State Medical Boards has a document pointing out that a physical exam is required for most diagnosis. Considering the state of malpractice today I am surprised that the clinics lawyers would allow a neurosurgeon to expose themselves to liability in who knows what jurisdiction. Even a consultation within Ohio like described exposed the NSGY to liability if the opinion was wrong. What was described went beyond a "curbside consult", even though the surgeon probably thinks that there is no exposure since they didn't physically see the patient. (google cybermedicine for a number of papers on the state of the legaL issues in online medicine)

Blog Tours:Charles Murtaugh asks if the Simpsons are back. I'd say yes, just on the basis of the sign in front of the church they attend: "Welcome disillusioned Catholics." Oh, and he also has a good post on the changing definition of "binge" drinking. (scroll up)

And The Bloviator points out that lawyers are now mining last summer’s media hype about hospital-aquired infections for gold.

While Rangel has some thoughts on malpractice and physician self-policing.

Smallpox Counterpoint: Email from a reader who opposes smallpox vaccine for the public:

I am an infectious disease physician in practice in Wisconsin. I served in the military and have long had a special interest in biological and chemical warfare, and have lectured on this subject on a number of occasions. I advocate and have received all kinds of vaccinations and have been involved in vaccine trials here at my medical center.

Yet, I am not in favor of the smallpox vaccine. Why? Because it is a relatively dangerous vaccine for a disease which doesn't exist. The need for smallpox vaccine rests on the possibility of a rogue regime having access to smallpox and deliberating infecting others, and that possibility should be subjected to the greatest possible scrutiny before we embark on a vaccination crusade.

Let me state my objections.

The side effects, which in your view have been exaggerated by infectious disease specialists, are real, and the incidence was almost certainly underestimated in the studies from the 1960's. A 1/20,000 chance of a horrible, life-threatening reaction is nothing to take lightly. Moreover, the public reaction to cases of progressive vaccinia or encephalitis probably cannot be overstated. I refer you to Gina Kolata's book "Flu" for a detailed analysis of what can go wrong with a vaccine program. (And swine flu vaccine, which I myself did receive, is a relatively safe vaccine.)

Please see also opinions of Dr. Vince Fulginiti, probably world's foremost living expert on vaccine side effects.

Many authorities believe that ring vaccination can control an intentional outbreak, and this approach was used successfully to eradicate smallpox in the past. Virtually every infectious disease expert of note, with a couple of high-profile exceptions, has advocated a go-slow approach on vaccination because of the issues noted above. This includes smallpox experts Donald Henderson (also advising president) and William Foege (head of CDC during
smallpox eradication).

While the public health worries about local costs ($800 per person) noted on your website are certainly an exaggeration, believe me, this thing won't get undertaken for free. In my state hundreds of personnel are being pulled from their usual duties to do nothing but this. The supplies alone are very expensive--special "breathable" dressings (?DuoDerm), etc. If we move to Stage 2, I guarantee you'll hear how much it costs. This is the very definition of an unfunded government mandate, even if the vaccine itself is "free". (I haven't heard who will pay for the cidofovir or VIG for vaccine reactions. I do know who'll pay for lost wages, medical care, etc. --workman's comp and private insurance, if the victim has it.)

Finally, we get down to the issue of duelling experts. I am an infectious disease "expert", for what that's worth. I give antibiotics and vaccines for a living. I respect the opinions of my colleagues the way you would respect those of your mentors and teachers. Those who have publicly disagreed (such as Carlos del Rio, Richard Wenzel, etc.) with the current policy have put themselves on the line. On the other hand, again and again I read of "biowarfare intelligence experts", CIA analysts--who are these anonymous analysts? I have not found a readily accessible CIA or government report which discusses the availability of smallpox outside protected compounds in Russia and the US in terms other than speculation. The CIA's website report on Iraq doesn't even mention it.

Virtually all bioterrorism news reports quote Ken Alibek, former head of Russia's biowar program. His opinions should be taken with a large grain of salt, as he currently hawks pro-immune-system vitamins and lurid audiotapes on the internet (stating, among other surprising opinions, that West Nile virus is an example of bioterrorism). Most significantly, in his book "Biohazard" he admits to feeling no moral qualms about developing weaponized anthrax and smallpox. And we should trust this guy??

Well, I've gone on too long, but you see the gist of my disagreement. As a doctor, I do not believe in giving a dangerous medicine for no demonstrably good purpose. Even if a public hyped up over war and terrorism clamors for it. (Would you prescribe an antibiotic for everyone who comes into your office and demands it?) I am skeptical of government authorities who want to tell us how to practice. I disdain federal pronouncements which amount to unfunded mandates. I believe in debating published data by named authors, then coming to a conclusion, not accepting Washington pronouncements at face value.

First, the smallpox vaccine program as it stands now is by no means an "unfunded mandate." It merely makes the vaccine available for those who want it. Only the military has to have it. For all others, healthcare workers included, it's voluntary. As for the vaccine complications, there's no reason to exclude health insurance companies from covering the care of a complication, just as they would cover the complication of any other medical treatment. Yes, the vaccine has a higher rate of serious complications than our current vaccines, but I believe that each person should be allowed to decide if those risks are something they want to take to protect themselves against a potential bioterrorist attack.

I've said this before, but I'll repeat it again. The ring vaccination strategy worked at a time when there was a high level of background immunity in the world population. That is no longer the case. It's overly optimistic to think that it would be as effective today. Even back in those days, it required a tremendous amount of effort on the part of those involved in the campaign to eradicate smallpox. It would be infinitely more difficult now. Half the world has absolutely no immunity to the disease, and we travel much more easily from place to place now than we did then.

As for the Russian biowar guy, I would expect someone who headed a bioweapons program to be of dubious moral quality. And, although I wouldn't trust him with my bank account, it would be hard to ignore his stories about his own work. Worse, there's no reason to think that he's the only person in the world who has "no moral qualms about developing weaponized anthrax and smallpox." Chances are, he knows them. So, while we might not be able to trust him, we certainly shouldn't ignore him.

I'm less skeptical of the government. I think they have weighed the problem carefully and decided that this is the best approach to take. Certainly, given the amount of brouhaha the public health community has made over giving a voluntary vaccine at a leisurely pace, you have to wonder how on earth they would give it involuntary to people they have to hunt down after an outbreak. That task would be far harder and far more expensive - and the repercussions far more serious.

Tuesday, January 07, 2003

E-Medicine: More and more tertiary care centers are offering online consultations, sight unseen, as in the case of this woman who wanted a second opinion about a CT scan result:

In Warner's case, she recently grew frustrated by the long waiting lists to get appointments with the nation's top neurosurgeons.

``This could be a tumor, and I didn't want to let that sit around,'' she said. ``I was worried sick.''

When she logged onto the Cleveland Clinic's Web site in search of information, she found a link to an online second opinion service...

She immediately gave her credit card number, filled out her medical history online and sent all her films and records to the Cleveland Clinic for review.

Five days and $565 later, a Cleveland Clinic neurosurgeon sent her a report via e-mail confirming what her local physician suspected: The mass was a harmless, non-cancerous cyst.

That might be fine for a second opinion radiology report, but caution should reign when applying it to most diseases. E-medicine provides only part of the equation that a doctor needs to assess a disease or a condition adequately. The physical exam plays a large part in wise medical decision making:

`Physicians who cannot examine a patient miss out on a lot of important information that isn't in a written or electronic record,'' she said. ``They can't see the person in front of them, so you lose all those personal things, from tone to body language -- the types of things you develop as a physician.''

For that reason, some hospitals won't provide online consultations or only offer them to international patients who can't get to the United States.

``By and large, I think the feeling of our physicians is if they're going to give a second opinion, they want to see the patient here,'' said Gary Stephenson, spokesman for Johns Hopkins Hospital in Baltimore.

Sometimes it's something as simple as a gesture, or a faint rash, or the feel of the skin, or the odor of the breath that can cinch a diagnosis. There's just no substitute for sight and touch.

What We Have Done and What We Have Failed to Do: A plastic surgeon argues that reducing medical errors is a better solution to the malpractice insurance crisis than tort reform:

In some states doctors in the more high-risk specialities like neurosurgery and obstetrics pay as much as $200,000 a year for malpractice insurance. I have not been sued for malpractice (yet). But my insurance premiums increase each year anyway, forcing me to raise my rates, too. If I'm a good doctor, why do I - and you - have to pay for the errors of others?

Making it more difficult to file malpractice suits and imposing caps on excessive awards for pain and suffering, as the surgeons in West Virginia are demanding, is a start. But this won't get to the deeper problem: Mistakes do happen, and they have consequences, sometimes dire ones. Rather than focusing on rewarding victims and their lawyers, we should concentrate on creating fewer victims - that means changing how we train doctors, track and correct errors and mete out punishment.

While reducing error rates is a commendable and worthy goal, there’s no reason to think that this would lower malpractice insurance premiums, nor the rate at which doctors are sued. Data already exists that show that most true cases of malpractice and error don’t result in lawsuits, and that many malpractice cases are of dubious worth. Lawsuits are a necessary evil. They provide us with a civil means of settling our disputes. No relationship is perfect. The doctor-patient relationship is no exception. Bad outcomes are sometimes inevitable. Even when all the decisions and actions were right and no errors occurred. And when things go wrong, we look for a place to cast blame. Even when no blame can justly be cast. It’s human nature. So, even in an error free system, we would still have lawsuits.

In fact, I’m not sure that the goal should be to reduce the number of lawsuits filed. People should have a right to file suit if they feel they’ve been wronged, no matter how misconceived that notion might be. Better to have the evidence out in an impartial court of law to settle the dispute once and for all than to have the misunderstanding fester forever. What should be curtailed are the unrestrained actions of lawyers who chase after cases of dubious merit to make a buck, who file suit against doctors without checking for culpability (as when they name every doctor whose name appears in a hospital chart), and who milk the jury system for sympathetic juries in the hope of hitting million dollar jackpots. That’s why tort reform is much more crucial to solving the malpractice crisis.

Resistance is Futile: Is there a new movement within medicine to save money at the expense of patients? National Review Online says “yes,” and it isn’t the brain child of insurance companies, but of hospitals and doctors and bioethicists:

As you read these words, quietly, slowly, inexorably, mostly behind the closed doors of hospital ethics committees, "futile care" or "inappropriate care" protocols are being put into place in hospitals throughout the country. The first time most patients and their families become aware that doctors are being given the right to say "no" to wanted medical treatment (other than comfort care) is during a medical crisis when they are at their most defenseless and vulnerable.

The article is about the trend among hospitals to put policies in place for dealing with the issue of futile care - care that’s not necessarily in the best interest of the patient. The article goes on to characterize futile care policies of hospitals as cost-saving measures, a means of rationing healthcare. This isn’t necessarily so. Nor is it a “stealth movement.” Futile care policies exist to help mediate disagreements between families and physicians. There are times when care is futile, and even harmful. But, for whatever reason, the family can’t accept that. (Sometimes it’s just too hard to let go.) Consider, for example this hypothetical (and admittedly overly optimistic) case of a child with a terminal illness. Or this very real, and much messier, instance of a family that can’t agree on treatment. Without futile care policies, there would be no forum for the family to express their view - outside the courts.

As in any system, there is the danger of abuse. A committee made up overwhelmingly of hospital employees, for example, could conceivably have the hospital’s best interest at heart rather than the patient’s or the family’s. (The constant references to wanting to free up a hospital bed for more acutely ill people with better hopes of survival in the second case above is an example.) But, the purpose and intent of the futile care policies truly isn’t to deny care. It’s to mediate. (Thanks to J. Bowen)

Monday, January 06, 2003

Paging Dr. Ben Casey: This love letter to politician doctors was more than a little surprising, especially coming from The New York Times:

Good doctors understand how affordable housing, a good education and secure jobs actually contribute to our physical health. I would rather trust a doctor to make a decision about war than I would a businessman or a lawyer; a doctor is more likely to remember the value of the lives he would be sacrificing.

Ah, that's sweet. And such a compliment to doctors. Unfortunately, it's an inaccurate assessment. While Doctors Dean and Frist may be very commendable and worthy men, you can't judge all doctors by them. Just sit through a few minutes of any hospital staff meeting and you'll soon realize that the the medical profession has more than its fair share of insufferable, arrogant asses. By the same token, there are many lawyers and businessmen out there who are men (and women) of great integrity. Better to judge our politicians by their actions and their ideas than by their professions.

A flier hanging on a pole in Brooklyn looks, at first glance, as if it might offer a room for rent or a job. There are phone numbers, dollar signs and tabs for people to tear off and take with them.

But the offer is intended for a specific group: drug-addicted men and women. "Get birth control, get cash," the flier reads. "If you are addicted to drugs and/or alcohol then this offer is for you."

While offers of birth control to drug addicts are common — distribution of condoms in particular, as a means not only for birth control but also to stem the spread of AIDS — this offer is much more radical. It offers men and women $200 to be sterilized or put on long-term birth control.

There is something a little creepy about offering to pay people, especially the poor and disadvantaged, to stop reproducing. Yet, it isn't much different than the stance that many people think our country should take internationally by paying poor and disadvantaged countries to stop reproducing; a stance which the current Adminstration has rejected, and for which it was criticized.

Smoke and Mirrors: The Bush Administration is coming under attack again for the composition of its scientific panels. This time it's the Secretary's Advisory Committee on Human Research Protections. Critics say that it is overwhelmingly composed of industry leaders, with no patient advocates. At first blush, it would seem that the Bush Administration cares not a whit about people, and that they're sacrificing the health of volunteers to industry inteterests. But, a closer look proves otherwise. The real issue is what sort of life is deserving of protection. The Bush Administration includes embryos and fetuses in the category of life, and that is what has stirred the ire of the critics.

One of the patient advocates who served on the Clinton version of this committee, but is not on the Bush version, is the president of the National Organization of Rare Disorders. NORD does a lot of good work. It’s a tremendous resource for people with rare diseases. It also happens to count among its hopes for some of those rare disorders, research on embryonic stem cells.

Then, there’s the guy who resigned immediately upon learning of his appointment. He wasn’t an industry leader, but a bioethicist, and also a former Clinton appointee. His reason for resigning:

.... he has no intention of joining, he said, given the committee's new embryo-oriented charter and its research industry-heavy membership, which includes the heads of research from several public and private for-profit research institutions.

It would have been less tilted toward industry if he had stayed on board, but evidently he’s too offended by the audacity of the Administration to consider embryos and fetuses as human life. Protesting the inclusion of embryos in the category of human life is evidently more important to him than protecting the interests of adult research subjects against industry.

The More Things Change: A musing on the death of Joe Strummer by the London Times had this observation:

The National Portrait Gallery has displayed a photograph of Mick Jagger close to an almost life-sized, and idealised, painting of Byron on his deathbed. The message was plain. The Byronic tradition of - mad, bad and dangerous to know - is alive and being maintained by present-day pop stars, in this case a young Mick Jagger.

The Plot Thickens: Looks like the "independent journalist" who was to verify the Raelian cloning claim may not be so independent after all. You know something's up when all of the major networks say "no thanks" to a story being pitched by one of their own:

His most ambitious proposal, for a reality-based program on the cloning effort, was made to Fox Entertainment several months ago, an executive at the company said. He said Dr. Guillen offered to produce the program and to be its host on the air. The program, Fox was told, would begin before the births of the clones and continue beyond, according to the executive.

Fox, which is not known for squeamishness — the network has produced "When Animals Attack" and "Who Wants to Marry a Multimillionaire?" — declined, in large part because the project seemed "loaded with ethical questions" as an entertainment program, the executive said.

More of the Same: Yet another story about how expensive it will be for public health departments to vaccinate healthcare workers:

In Syracuse, health officials estimated that they would need $475,000 to vaccinate about 600 health workers at five hospitals in Onondaga County.

That's almost $800 a person. Come, come. There's no reason administering a vaccine that has been supplied for free by the government would cost such an exorbitant amount.

What the public health community is really saying is that they don't want to do this. Having proven themselves unequal to the task of assessing the need for the vaccine in the first place, they are now proving themselves unequal to the task of administering it. Perhaps the task should be delegated to others. There's really no reason that the vaccine would have to be given through public health departments. Hospitals have employee health services that provide such services as hepatits B immunizations. Why not train the community physicians and hospital staff to adminster the vaccine and let it be done on site? And as for administering it to the public, again, that doesn't have to be done by public health departments. Community physicians are just as capable of learning to administer a smallpox vaccine as public health nurses.

These stories also do absolutely nothing to bolster confidence in the public health system's ability to respond to a smallpox attack. If they can't find the will to administer vaccine at a leisurely pace, how on earth would they administer it in the seven day window after a smallpox outbreak?

Sunday, January 05, 2003

Hiatus: My husband just dropped the New York Times on the table, and I see some tempting stories, but I’ve been up since 3AM when I had to go in to evaluate a hospitalized patient with the sudden onset of severe abdominal pain. (It turned out to be a rectus sheath hematoma.) My adrenaline rush has left me. Blogging will have to wait. I’m going back to bed.

Med Mal Circuit: The medical malpractice insurance problem continues to be a thorn in the side of doctors everywhere. In Tampa hospitals are letting neurosurgeons practice without insurance (The surgeons must be terribly dedicated to take that risk. One bad case could be your ruin):

Four doctors at the hospital quit practicing there recently because they cannot get malpractice insurance or do not want to pay the increased costs. The loss of those doctors, and possibly more, could affect patient care, hospital Chief Executive Officer Alan Levine said Friday.

To maintain neurosurgery service, Levine recommended waivers for two neurosurgeons so they could work without malpractice insurance, which is known in medical circles as ``going bare.'' The hospital board approved the waivers.

At least two other hospitals in the area, Tampa General and University Community, have faced similar problems and recently changed regulations to allow staff doctors to work without malpractice insurance.

Interestingly, Florida prohibits insurance companies from investing more than 15% of their profits in the stock market, yet they still have the same malpractice insurance problems that everyone else has. So much for the trial lawyer argument that the problem is caused by bad investments.

And in a small community in Illinois, doctors are leaving for greener pastures:

Some notable departures from the staffs at Alton Memorial and Saint Anthony's Health Center are Dr. Robert Hamilton, a general surgeon, who retired at 63 a year ago after 29 years of service in the area; Dr. Bryan Lohrbach, an orthopedist, who moved to Appleton, Wis.; and Dr. Nick Lorens, a gastroenterologist, who moved to Columbia, Mo. Lohrbach saved more than $50,000 a year in malpractice insurance premiums with the move to Wisconsin. Lorens' malpractice premiums were half as much in Columbia.

Meanwhile, lawyers and healthcare insurance providers are protesting the reforms proposed in Pennsylvania. The lawyers' complaints are typical, and of not much merit. Here's one lawyer's comments on the proposal to require certificates of merit from independent physicians before a case can be filed :

Ambrose said he doubts that Rendell's proposal to require certificates of merit in medical malpractice cases would dramatically lower the number of cases filed each year. Rendell's Medical Malpractice Liability Task Force estimated it would reduce the number of cases filed by 25 percent.

"In Pennsylvania, you can't file an action until you have an opinion from a board-certified physician who practices in the area," Ambrose said. "That opinion must state that the doctor in question deviated from the standard of care and caused injury or death to occur."

Yes, but how independent is that board-certified physician? Is he on the law firm's payroll to provide them with just that sort of statement? An independent physician would be much more trustworthy than one hired by either party, and it's difficult to see what would be so objectionable about that. Unless of course, you're afraid it'll cut into your income by curtailing the number of suits you can file.

The healthcare insurance companies, however, have a legitimate gripe. The plan calls for them to cover some of the costs of doctor's malpractice insurance premiums. That makes no sense at all, and in the end could do far more harm than good. Forced to pay for malpractice insurance, healthcare insurers surely would decrease reimbursements to physicians and increase rates to consumers. Far better to keep the malpractice issue where it belongs: among doctors, lawyers, malpractice insurance companies, and the tort system.

Mending Hearts: There’s been another advancement in the use of adult stem cells to treat disease. A team of researchers has coaxed bone marrow stem cells into growing into heart muscle:

Stem cells come from the patient's own marrow so there is no risk of rejectionIf the patient survives, s/he usually suffers disabling symptoms because of tissue damage that affects blood flow to the heart. These include chest pain and breathlessness, which can result in poor quality of life.

The new procedure involves harvesting stem cells - types of cells present in bone marrow capable of developing into different kinds of tissue and muscle - from the patient and then transplanting them directly into the damaged heart tissue via a special catheter.

The researchers claim all the patients who took part in the study failed to respond to traditional methods and surgical procedures. After the stem cell transplant, all had strikingly improved blood flow to the heart and heart functions.

There’s a lot to hope for from adult stem cell research, and it avoids the ethical dilemmas of embryonic stem cell research.

Happiness is Self-Determination: According to a recent survey in the BMJ 22% of British physicians would like to quit. The British Medical Association says it’s because:

...a lot of treatment which used to be carried out in hospitals is now handled at GPs surgeries, where doctors feel they have lost control over the way they work.

The Guardian says not to worry, the discontent is only among the older set, who are more prone to burn-out. But, a look at the results reveals that the percentage of that group who wants to quit has increased significantly since 1998. It’s also true that this is the group that’s more likely to act on those wishes, since they have fewer financial responsibilities. Their houses are more likely to be paid for, their education loans paid off, their children finished with schooling. The NHS should pay attention. The dissatisfaction isn’t just the middle-age career crisis of an aging baby-boomer generation. It’s much deeper and more systemic than that.

Vanity Press: There's an organization called the Public Library of Science that's planning to publish two free on-line journals, one in biology and one in medicine. They will be free to the readers, but not to the authors. They will have to pay $1500 to have a paper published. So much for peer review, huh? Have cash, can publish.

Here's a better idea. Established journals could make their content available online for free and finance it with a pledge-week like Andrew Sullivan recently did. There's a lot to be said for having a journal in hand sometimes, so they can still get the majority of their money through their traditional mail-based subscriptions, but at the same time make a their content available to the wider public. And maintain the integrity of the publishing process.